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Ann Thorac Surg 1998;65:939-942
© 1998 The Society of Thoracic Surgeons

Bilateral Lung Volume Reduction Surgery via Median Sternotomy for Severe Pulmonary Emphysema

^a Department of Surgery II, Okayama University School of Medicine, Okayama, Japan
^b Department of Anesthesiology and Resuscitology, Okayama University School of Medicine, Okayama, Japan
^c Department of Rehabilitation, Okayama University School of Medicine, Okayama, Japan
^d Department of Radiology, Okayama University School of Medicine, Okayama, Japan
^e Department of Internal Medicine, Minami-Okayama Hospital, Okayama, Japan

Accepted for publication November 28, 1997.

Address reprint requests to Dr Date, Department of Surgery II, Okayama University School of Medicine, 2-5-1 Shikata Cho, Okayama 700, Japan

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. Lung volume reduction surgery either via sternotomy or by thoracoscopy has been demonstrated to be effective for selected emphysema patients in North America and Europe. The present study summarizes short-term results of bilateral lung volume reduction performed via median sternotomy for the first consecutive 39 patients with severe diffuse emphysema in Okayama, Japan, from July 1995 to February 1997.

Methods. There were 35 men and 4 women, and the age range was 54 to 74 years with a mean age of 65 years. All were former heavy smokers and none of them had ₁- antitrypsin deficiency. Only 9 patients (23%) showed a bilateral upper lobe pattern of emphysema. The operation was done through a median sternotomy, and the most emphysematous portions were excised bilaterally with a linear stapling device fitted with strips of bovine pericardium to prevent air leakage.

Results. No operative death was encountered. The first 33 patients completed 3-month follow-up assessment, and their mean forced expiratory volume in 1 second had improved by 41% from 735 mL to 1,037 mL. Other parameters of pulmonary function tests, arterial blood gas analysis, 6-minute walking distance, and dyspnea scale also had improved significantly. These improvements lasted for at least a year.

Conclusions. Bilateral lung volume reduction surgery via median sternotomy is a safe and effective procedure for selected severe emphysema patients. Although the pattern of emphysema might be different between countries, the results in Japanese patients were similar to those previously reported in North American and European patients.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
Recently published reports from North America and Europe have demonstrated that lung volume reduction surgery (LVRS) either via sternotomy [1–6] or by thoracoscopy [7–12] provides significant short-term improvement in respiratory status in selected emphysema patients with acceptable morbidity and mortality. About 55% of Japanese men are currently smokers, and more than 10,000 patients are receiving home oxygen therapy for chronic obstructive lung disease. This study details the results of our initial experience of LVRS performed via median sternotomy in Okayama, Japan.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
Patient selection
Preoperative workup consisted of posteroanterior and left lateral chest roentgenograms (at maximal inspiration and expiration), computed tomographic scan of the chest, differential ventilation/perfusion lung scan, complete pulmonary function tests, measurement of room air blood gases, resting radionuclide ventriculogram, right heart catheterization, Doppler echocardiogram, and 6-minute walk test. The workup was performed at Okayama University School of Medicine. Inclusion and exclusion criteria were as follows:

1. Inclusion criteria

   Marked restriction in activities of daily living despite maximal medical therapy (modified Medical Research Council dyspnea scale [13] = grade 2 or greater)
   

   Marked hyperinflation (total lung capacity >120%)
   

   Diffuse but inhomogeneous emphysema (existence of target areas)
   

   Ability to participate in a vigorous pulmonary rehabilitation program
   

   Smoking cessation for more than 3 months
   

   
   
   
2. Exclusion criteria

   Pulmonary hypertension (mean pulmonary arterial pressure > 30 mm Hg)
   

   Active bronchopulmonary infection
   

   Severe bronchial asthma
   

   Severe pleural adhesion (prior thoracotomy, chemical pleurodesis, tuberculosis)
   

   Hypercapnea (arterial carbon dioxide tension >60 mm Hg)
   

   Significant other organ dysfunction
   

   
   

Preoperative rehabilitation and preparation
Once accepted as candidates for LVRS, patients were admitted to Minami-Okayama Hospital, where they were enrolled in a pulmonary rehabilitation program for 1 to 3 months. During the preoperative rehabilitation period, maximal medical treatment was provided by experienced pulmonologists. Nutritional support was also given to the patients with marked body weight loss. Two patients gave up smoking at the initiation of the pulmonary rehabilitation. The mean forced expiratory volume in 1 second increased significantly by 11% from 671 mL (range, 340 to 1,200 mL) to 735 mL (range, 510 to 1,350 mL), and 6-minute walking distance increased by 15% from 314 m to 361 m during the preoperative preparation.

Operative technique
All the patients received operation at Okayama University School of Medicine. Bilateral LVRS was performed via median sternotomy, and the most emphysematous portions of the lungs were excised bilaterally using a linear stapling device fitted with strips of bovine pericardium to prevent air leakage, as previously described [14]. The areas of the lung to be resected were primarily determined by the preoperative roentgenographic findings obtained from computed tomographic scan and ventilation/perfusion lung scan. However, the final decision on what to resect was made during the lung reduction procedure based on the macroscopic findings under one-lung ventilation. The lung was reinflated and the decision was made as to whether or not further lung tissue should be excised based on the overall size of the lung. Saline solution was then introduced into the chest to assess air leakage. When air leaks were identified, they were stapled with polyglycolic acid sheet buttress. Sites of air leaks not amenable to direct stapling were treated with fibrin glue instillation. One or two chest tubes were placed in each pleural space.

Postoperative care and follow-up
All patients but 1 were extubated at the end of the procedure. One patient was extubated 6 hours after the operation. The patients usually spent 1 day in the intensive care unit and were transferred to the regular ward. Postoperative analgesia was provided by a mixture of 0.125% bupivacaine with 5 µg/mL fentanyl administered through the thoracic epidural catheter. An intensive program of chest physiotherapy was given every 4 hours, and postoperative pulmonary rehabilitation was initiated as soon as possible. Postoperatively, complete pulmonary function tests, measurement of room air blood gases, and 6-minute walk test were performed at 1, 2, 3, 6, and 12 months.

Statistical analysis
All data are presented as the mean ± the standard error of the mean. The relationships between the preoperative and postoperative data were analyzed with use of the paired Student’s t test for parametric data and the ² test for nonparametric data. Repeated-measures analysis of variance was used to test the effect of the operation on several parameters during the first year. Statistical significance was determined at a p value of 0.05.

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
From July 1995 through February 1997, 39 patients with severe pulmonary emphysema underwent bilateral LVRS via median sternotomy. Two patients in whom unilateral LVRS was performed were excluded from further analysis. There were 35 men and 4 women with a mean age of 65 years (range, 54 to 74 years). All were former heavy smokers, and none of them had ₁-antitrypsin deficiency. Twenty-six patients (67%) required supplemental oxygen, and 12 patients (31%) were taking regular doses of oral prednisone.

The mean duration of the operations was 169 minutes, with a minimum of 100 minutes and a maximum of 275 minutes. The linear stapler was fired 9.9 ± 0.4 times on average. The average amount of lung removed was 104 ± 7 g (range, 51 to 267 g).

The operative morbidity is depicted in Table 1. The most frequent complication was prolonged air leak. However, no pleural infection was encountered. The average duration of chest tube drainage required was 10.2 ± 1.2 days. Five patients required reoperation for sudden development of massive air leakage 2 to 4 days after the operation. Four patients were found to have a rupture on the surface of the residual bulla apart from the staple lines. One patient had a tiny rupture at the base of the staple line. All 5 patients were successfully treated by plicating the leaking area with a staple line buttressed with a polyglycolic acid sheet.

The follow-up ranged 1 to 20 months, with 33 patients at 3 months or more. The results of these consecutive 33 patients were used to evaluate the effect of bilateral LVRS (Table 2). Preoperative data were obtained immediately before the operation after the patient received maximal medical treatment and pulmonary rehabilitation for 1 to 3 months. Bilateral LVRS provided significant improvement in forced expiratory volume in 1 second, lung volume measurements, arterial blood gases, 6-minute walking distance, and dyspnea scale. The beneficial effects of bilateral LVRS were maintained through a 1-year follow-up period (Fig 1). Ten patients currently require supplemental oxygen, compared with 26 patients before operation.

View larger version (71K): [in this window] [in a new window]   Fig 1. Forced expiratory volume in 1 second (FEV1) and 6-minute walking distance before operation (n = 33) and 1 month (n = 33), 2 months (n = 33), 3 months (n = 33), 6 months (n = 20), and 12 months (n = 9) after operation. For FEV1, p < 0.001 at all postoperative time points versus preoperative data. For 6-minute walking distance, p < 0.01 at 2, 3, and 6 months and 1 year versus preoperative data. (Pre-R = before rehabilitation [before operation]; Post-R = after rehabilitation [before operation].)

Nine patients (23%) were classified as having upper lobe type, 11 patients (28%) as having lower lobe type, and 19 patients (49%) as having mixed type. In the 33 patients followed up for more than 3 months, the improvement in forced expiratory volume in 1 second was significantly better in the upper lobe type (82% ± 8%) than the lower lobe type (39% ± 10%) and the mixed type (23% ± 8%) (p < 0.01).

	Comment

Top Abstract Introduction Patients and methods Results Comment References

 
Lung volume reduction surgery either via sternotomy [1–6] or by thoracoscopy [7–12] has been proved to provide significant short-term improvement in respiratory status in selected emphysema patients in North America and Europe. These results spurred many Japanese surgeons to institute LVRS program recently. Because Dr Date was trained by Dr Joel D. Cooper and his colleagues, the LVRS program in Okayama started in July 1995 is similar to the one at Washington University in terms of patient selection, surgical technique, and perioperative management including pulmonary rehabilitation.

Meticulous preoperative preparation is very important to treat these very fragile patients. Pulmonary rehabilitation is undoubtedly the most important component of preoperative preparation, as has been proved by the improvement in 6-minute walking distance. The significant improvement in forced expiratory volume in 1 second by 11% obtained during the preoperative preparation period proved the importance of the proper and maximal medical treatment provided by the experienced pulmonologists. Oral theophylline, anticholinergic inhalation, and ß-stimulant inhalation were routinely given to all candidates, and oral or inhaled steroid was administered when indicated.

Persistent air leakage was the most common postoperative complication. Forty-six percent of patients required chest tubes for more than 7 days. Although air leakage at the staple line was completely eliminated with the use of the bovine pericardium, air leakage from the injury to the lung during pleural dissection was problematic because pleural adhesion was encountered in 80% of our patients. Nevertheless, no pleural infection was experienced, and our average duration of chest tube drainage (10.2 days) was similar to those of the previous reports.

Five patients required reoperation for sudden development of massive air leakage. Four of the 5 patients were found to have a rupture on the surface of the residual bulla apart from the staple lines. This complication has been reported by others [1, 6] as well and is believed to be caused by excessive tension on the residual bulla. We did not experience this complication in the last 10 cases after we started to avoid chest tube suction as was recommended by Cooper and Patterson [15].

It has been clearly shown that patients with upper lobe type emphysema have greater improvement after LVRS than do patients with lower lobe type emphysema [16–19]. Although the method to classify the pattern of emphysema has not been clearly established, it appears that more than half of the patients who have undergone LVRS in North America had upper lobe type emphysema. In contrast, only 23% of our patients in Japan were classified as having upper lobe type emphysema. Whether this is because of the difference in patient selection or the difference in the incidence of upper lobe type emphysema between countries is not known. Because the mean improvement of forced expiratory volume in 1 second was limited in patients with mixed type disease, one has to be careful in offering this operation to such patients.

In spite of the high incidence of pleural adhesion and low incidence of upper lobe type emphysema, our results in Japanese patients were similar to those previously reported in North American and European patients. The average improvement noted by us in forced expiratory volume in 1 second, 41%, is not greater but similar to those reported for the bilateral approach: 57% [2], 83% [4], 61% [5], and 40% [6] for the open approach, and 52% [10] and 42% [12] for the thoracoscopic approach. The improvement is better than those reported for the thoracoscopic unilateral approach: 30% [7], 15% [8], 27% [9], 33% [10], and 35% [11]. Of note was that this improvement was observed only 1 month after the operation and lasted for at least 1 year.

Because acceptable results have been documented for both the thoracoscopic and open approaches, it appears reasonable to conclude that the choice of operative approach is not so important. Just as several different approaches have been used for esophagectomy, one may choose an appropriate approach for LVRS according to the patient’s condition, disease distribution, and degree of pleural adhesion. However, we would like to emphasize that median sternotomy is not an invasive approach because no operative death and early functional recovery were demonstrated in our experience.

	References

Top Abstract Introduction Patients and methods Results Comment References

 

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